HDIS Assignment of Benefits for Medicare, Medicaid, & Insurance

An Assignment of Benefits, or an AOB is a document that allows HDIS to bill Medicaid and your insurance company on your behalf for the supplies we send you.

Without this form completed and on file for you HDIS cannot send orders or bill on your behalf.

We appreciate your help with this. If you have any questions about this requirement or anything else please reach out to our customer service specialists.

Contact:
Phone: 1-800-367-8360
Email: custcare@hdismedicaid.com

View HDIS Medicaid Webpage >

What HDIS does for you!

We will take care of every detail! HDIS will contact your doctors for all of the paperwork and take care of your billing.
No Hassle Renewals! HDIS will call and confirm an order is needed before you run out.
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Personalized Product Consultation from our Trusted Advisors.
Product Samples are available to make sure you get the correct fit!

HDIS Assignment of Benefits (AOB)

Medicaid Recipient First Name

Medicaid Recipient Last Name

Name of Person Completing the Form

Relationship to Medicaid Recipient

Medicaid Recipient Phone Number

Medicaid Recipient Email Address

Medicaid Recipient Street Address

Medicaid Recipient Street Address 2

Medicaid Recipient City

State

Medicaid Recipient ZIP Code

Agree To Terms

By checking this box, I acknowledge and agree to the following:

I have received a copy of the Medicare Supplier Standards, Customer Rights and Responsibilities, Grievance Reporting, and the Notice of Privacy Practices from HDIS, and I understand the content of these documents.
I have received training and/or documentation on how to use the supplies provided.
I acknowledge that I am not currently using another supplier for any of my supplies ordered through HDIS.
I understand my financial responsibilities as they have been explained to me. I understand I will be responsible for any deductibles, coinsurance, or charges denied by my coverage. For additional information on your benefits and your financial responsibility, please go to https://www.medicare.gov, or contact your Medicaid or insurance provider for plan-specific coverage.
If HDIS is unable to obtain an Explanation of Benefits from my insurance company, I understand that it is my responsibility to send all Explanations of Benefits to HDIS upon receiving them. Failure to do so could result in a possible delay in shipments.
I understand that Medicare, Medicaid or my private insurance may require/allow coverage of Medical supplies on a rental basis. I understand that HDIS does not rent any items and will be unable to provide items where rental is required or desired.
I authorize HDIS to contact my physician to obtain a prescription, contact my insurance provider to verify my benefits and to contact me to discuss my order. I authorize my physician to release my information to HDIS for the purpose of processing and submitting claims to Medicare and/or other insurer(s) for products authorized by me. I authorize HDIS to submit claims on my behalf and to use this signature on file form in lieu of my actual signature on each claim form.

HDIS Assignment of Benefits for Medicare, Medicaid, & Insurance

What HDIS does for you!

HDIS Assignment of Benefits (AOB)

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